I love MICU: reason #1

I realize the past few posts have been harsh and negative. But there are a lot of nights I do love my job, love the ICU. So I'm gonna tell you about when I love the ICU.

Reason #1 is The ICU means Intensive care...

We do have the classic drama like on tv, (only always in the ER...the ICU does not have its own tv show.) I was there for our last cracked chest in the ICU...which does not happen in the ER. A suture on the junction from the pt's aorta to her heart muscle tore. Blood. Everywhere. Liters and liters of it. God, it was bad.

And tell me why don't we have our own tv show? Not that the ED isn't interesting, it very much is. But. But. The ICU is cool, too.

They don't have situations like my patient the other night in the ER.

Margaret is not my patient's name, and she's a train wreck. She came in for a complex vascular surgical procedure, developed a bleed...and 36 hours later she's in multiple organ system failure. Yeah. That fast.

In ICU, you meet patients at a life-or-death time of their lives. Margaret has in her living will that she does not want to be on life support for more than seven days. Today is day five. Don't think that isn't at the forefront at my mind at all times. A week ago, she was living at home independently. Having cups of coffee with her friends. Visiting with her grandchildren, walking her poodle. This was a scheduled, planned, surgery.

On this particular patient, we don't have an intensivist or hospitalist, so there is no one single MD brain drivin this train. It leaves a lot of holes for the RN to fill. I'm not going to blog on the appropriateness of this (it isn't) right now. What it does mean is that the day RN with whom I'm swapping this patient every day (Douglas) and I are operating in a frustrating vacuum. And a clinically challenging one.

What I do love about taking care of this type of patient is that I was busy all night titrating drips, titrating the vent, titrating the CRRT, getting the next round of labs and futzing all over again. Dressing changes, lab values to interpret, arterial and central venous pressure line waveforms to futz with. Oh, and she has a paced rhythm, too.

...I can't seem to get Margaret off the dopamine, even with cutting her CRRT rate in half. Her central venous pressure is THIRTY, and I'm slurpin out fluid at almost hemodialysis rates. But I stop that, hold the whiff of dopamine I'm giving her, her pressure tanks. Her heart likes the inotrope. Weird. (Gee, I wish I had an intensivist here who might have some more ideas on what's up with that....)

Incremental success for this patient is decreasing her oxygen by 5% and having her tolerate it for an hour. Five percent is no piffle. It will be the difference between whether or not she can attempt to wean off the machine, i.e. recovering or not. I am continually testing how her body responds to the changes in the meds, changes in the amount of fluid I'm pulling off her body, in the vent settings.

Let me underline: We have two days left to fix her. Before the family draws the line because of Margaret's previously stated wishes. If we can't fix her, we will stop the kidney machine, take the tube out of her throat and she will essentially....drown. In her own body fluids. Of course we're gonna have pain and sedation meds on board, but I realize how horrible this is.

We have 48 hours. Where else but in the ICU do you have this kind of situation?

In the ER, some of their adrenaline comes from the chaos, the randomness, the wildness. 'Turn and burn' is what the ED nurses tell me. It's a different adrenaline in the ICU. Continuous dose adrenaline, maybe. Adrenaline for control freaks (wonder if the OR is like that, too?) I didn't sleep well today, because I was thinking about what I may have forgotten, what I could have altered or improved.

I don't know Margaret. I see the pictures of her in her room. But my head is totally wrapped up in what we need to do to help her body heal from the inside out. Why the drop in crit this morning? Where is the bleed? Do we need to give her platelets because the CRRT is chewing them up? Why can't we get her off that blasted dopamine? Why is it sometimes I can doppler that left post tib, and sometimes I get it on the right but not consistently? What's going on with those sutures in there? Why are her LFTs still high even after we've stabilized her pressures? I wish I had a PA cath to see what's really happening with her hemodynamically. Her lungs DO sound better, but when she turns to the left, her sats drop, I wonder if we don't have an infiltrate on the right? Her CRRT "arterial" pressure kept alarming negative pressures, which might imply that she's vasodilating...etiology? Sepsis? No, we have her on enough abx to sterilize a barn. What are my other types of shock: spinal, no, anaphylactic, no, cardiogenic shock? That's the only one left...? Why, in a paced patient? Is that why I can't get off the dopamine? What's gonna help her...well if we do levo, we completely nullify the surgery that she came in here for...

Round and round.

I love this. I really do.


But reason #1 might be the reason ICU is Intensive Care. We have a different definition of intense here. It's not better or worse than similar nursing areas....and this kind suits me. I'm glad they love the 'turn and burn' in the ER, I'm glad they have the extremely sedated almost-dead patients that they 'put down' and revive in the OR, and that's not even the people that do oncology, or scarier...pediatric oncology. Intense in different ways.

We have 36 hours left to get her off that vent. It's a proFOUNDly complex puzzle for the team of people working with her to disentangle.

And it means life or death for Margaret. I'm sitting in her room, surrounded by pictures of her family, her pooch. They're waiting on us to be smart enough to get her out of this.

Thirty-six hours.

Crazy old bat stole my car keys.

The other day, some crazy old bat stole my keys. My housekeys, carkeys. Fortunately for me, I have a spare flat carkey in my wallet and my sister's got a copy of my housekeys.

How do I know she stole them? I don't for sure. I can tell you what happened, though.

I know that this crazy woman had to be tied down by yours truly to prevent her from ripping out two fat flank chest tubes, her peripheral iv, and her epidural catheter. She scratched me up. As I tried to get her changed out of her bloody hospital gown and into a clean one, I and my charge RN, Rita had to restrain her from crawlin out of bed naked and screaming. We got the blood cleaned up, the chest tube dressing reinforced, and her body and then eventually her hands tied down so she'd quit yankin on stuff placed for good reason into her body.

I know she tried to take the epidural keys, which I'd set on the bed as I fiddled with changing the epidural med (to something less likely to make her barking mad and paranoid). I noticed and asked, What are you doing? I don't think I listened to the answer, I just took the keys back out of where she was trying to bury them.

My keys were found two days later in the laundry bag. The laundry bags that are changed qshift. The ones that, had the keys been in there originally because I may have accidentally dropped them there, would have been either found on my shift or sent to the facility laundry several days ago, when I actually took care of the patient. But they were found yesterday by housekeeping. In the laundry basket. Nobody knows how they got there, two days after I'd lost them. One of my very kind and considerate colleagues locked them up in her locker.

Crazy ol bat.

I know I'm supposed to feel this well of compassion for this frail elderly woman who is medically complex, and confused, and going through a great deal of mental anguish not to mention that chest tubes HURT. I recall the moments when she said, after begging me to untie her, and me explaining it is not safe for her to do so...."I'm very disappointed in my daughter that she's allowing this to happen to me." It genuinely broke my heart. That frail old woman was absolutely aware that I'd tied her down; she felt shame and humiliation and at that moment, absolutely blamed her daughter for it. And she was disappointed. She was incapable of cognitively reasoning that she cannot pull out the tubes lodged into her chest, because she was utterly convinced that we were trying to kill her. At least, that's what the police officer said when he called the unit to tell us a Mrs. So and So had called 911 on us. (Thank you, Officer, no. Yes. I'll keep the phone out of reach until she's more oriented. Sorry to trouble you, thank you. Yes, good night.)

(I said to Carmen, an RN I know with a light heart & humor, "She called the cops on us." "Cool! Did they come?" It got me to giggle after all the blood and paranoia and stupid sturm and drang.)

And it's her daughter's fault, and she was very disappointed.

I'd been on the phone with same daughter many, many times that night to update her on her mother's condition, and the daughter explained the family history of dementia and odd bursts of paranoia, and how this happened on her mother's previous surgery. I could hear the daughter wring her hands, and ask what she should do, should she come down there? Would that help her?

I reassured the daughter that her mother appeared to be suffering from some confusion related to the recent anesthesia. How it would be easier on both of them for the mother to be angry at me. How there's nothing to be done but keep her mother from hurting herself and wait for it to clear. How the physicians were all aware of what was happening, and their plan was simply to wait and let it clear. How she should try and rest and come in the next morning.

And the mother, I'm sure, shot some stinging accusation at her daughter the next morning. Stinging words she thinks she means right now, and the daughter will really feel. I feel awful for them both because of that.

I know all these things. And I did feel genuine compassion at the time.

Then I realized the old bitch stole my keys.

Is it okay to be annoyed?

I loved this:

From Head Nurse.

I updated my resume tonight to toss it in the pile to be considered for the weekend option. The differential is roughly 40% of my base. I hear I don't have to be "oriented to hearts" yet, either.

("Oriented to hearts" is something of a sensible gatekeeping thing to prevent newer ICU people from getting a patient they cannot handle, with a mixture of bullshit mother-hen pecking order alpha-queen-bee-old-nurse doctor-coddling thing on my unit.) (Some other time, maybe I'll post about it.)

So. I'm tossing my resume in. I know there are others in the pile already, and the due date is 4/15. Shall see what happens.

Updating your resume tends to get you thinking hard about how much or little you love your job. Which is it for me?

Um. Five...?

Head Nurse's words were good to hear. My answer to whether or not my job is still 5. But now, I'm thinkin this is an okay answer today. Tomorrow might be a resounding yes, love my job.

Today, I don't have my car keys back in my hot little hands yet. (See post above.) So today's probably not the best day to cast a vote. I liked Head Nurse's words.

Know what I wonder whenever we get an overdose into the ICU?

Why today?

I always wonder that. Usually they're too somnolent/unconscious/intubated or bleeding out from fulminant liver failure to tell me.

But I always wonder what it was about...T O D A Y.

February 10, 2008 was a special day for this person. They picked today to try and die.

I wonder why.

Critical care class, weeks 1 & 2

This summer my world was all about the social life. It's fall again, and focus is back on work. Quite a lot goin on at the moment.

Critical care class is going fine. I'm with six others: an pediatric OR RN with 5 yrs experience there, an oncology RN (brand new OCN) with eight? years experience, a med-surg RN with two years behind her, an ortho RN with 8 years ortho/med-surg behind him, and two new grads.

Love hemodynamics. LOVE IT. It's new stuff to me, and I'm getting it and my brain is actually working again! Love it! Twelve lead stuff, too...it's not new, but my understanding of it's always been superficial. I'm getting some more depth to that, and that's fun, too. There's a lot to 12lead, so I'm looking forward to taking the class proper. This is the good stuff about CCclass.

However. Because we have to start as if everybody's a new grad, I'm bored half the time. I've had so many people tell me how ass-kicking this class is....and I really shouldn't be this cocky halfway through. I'm just used to measuring troponins and know the heparin nomogram, and know what adventitious heart sounds are. That kind of stuff.

I'm not always at the top of my game. Doing the drip calculations my instructor's way caused me great pain. She uses something she calls "a magic number" to calculate drip rates and she is unable to do the calculations the long way. The ortho RN and I both needed it proved to us, so we put our heads together and over a period of two hours, figured out why the shortcut works. Others in the class just accepted the shortcut and were okay saying that they use a "magic number" to calculate a lifesaving drug drip factor for a critically ill patient. My father is an engineer. Math is NOT MAGIC.

I'm anticipating that once we're out of cardiac and into other body systems, I'll be working harder. There is SO MUCH that I don't know about ICU nursing, and my critical care class should be harder on me than it is so far. In a real ICU, I would get my ass handed to me and I know it. I'm a little nervous that I'm not worrying yet in this class. Again, maybe I'm being cocky and on the exam, I will get my ass handed to me.

But certain comments my instructor makes give me pause. Me, "Instructorperson, will we be going through the clotting cascade and stuff when we do livers? I don't know a lot of that stuff." "Yes, we'll be going through that when we do DIC. Probably not deeply enough for you, but we will be going through it." And what is that supposed to mean "not enough for me"? I'm sorry, am I bugging you?

Yeah, and?

So I got my ACLS certification two weeks ago. This means that I can now go along to the codes and rapid responses in MyHospital. Supposed to go to three, then I can be "Team Lead #2" for three, then "Team Lead #1". That's what I was told.

The idea of being "Team Lead" when somebody's dead and I'm supposed to fix it is a little as yet horrifying to me. I know sometime I'll learn and get over this, because I see that other people do and have. I do want to do this. It's part of my job, the most basic part. How I've had the dumb luck to not be present for any codes on my unit these five months is likely just the nature of MyHospital's ICU. We are not a trauma shop.

So a few nights ago, it's 2030, and the chimes ring. I think "yay!", but don't tell anybody that. I know you're secretly perky and happy about chimes only for a very short while in your nursing career. "Rapid Response, room 5432" I tell a few people I'm going...actually, I ask, cos I'm not used to this. Bump into J, the resource nurse, on my way and we're off to room 5432.

A respiratory therapist is already there. I also L, who I know from my old unit, and she is directing everybody and bossing people around. (This is a common pose.) I say hi. She doesn't acknowledge me...she's giving report on the patient: 90something year old woman, DNR, respiratory distress, sats 77%, history of COPD, CHF, CAD, DM, and PME...Pretty Much Everything. L is actually not the patient's nurse, and she's not even on our shift. I roll my eyes because I can.

Sure enough, there's a little old lady in bed breathing badly...with a nasal cannula on (and in her nose). She's tachy, but I don't see a blood pressure on the dynamap. There's one RT so far and the patient's nurse (M) and some other random person, the house supervisor and me and J (resource nurse) all in the room. Heckovit is, what I'm seeing is yeah, not good, but er, not four alarm fire alarm. Maybe only two. Or one and a half. I've had my patients be like this and I've fixed them. Okay. This is not scary or intimidating. (Part of me is a little disappointed. Isn't that awful? Cos the little old lady in bed is having a four alarm fire drill day.)

J does something I didn't expect her to do: she pushes me up to the bedside first. Takes me a split-second to think: Huh?...Oh...Good.

I ask "Can I get a blood pressure?" Nurse M tells me the dynamap isn't working right. I don't actually glare at her for that, yay for me. Her thinking returns, and she gets a manual pressure while I lung-listen and I hear: (drumroll please)

COPD lungs.

I ask: "When did she get the MedicationName last?" Patient was just like you'd expect for a 90something 80lbs soaking wet COPDer...inspiration but no expiration, fine crackles, dim in the bases. Woman's got no alveoli left. Whaddya think you're gonna hear? This isn't an acute PE, this isn't any acute anything, this is get some oxygen into her mouth and calm the little old lady down. Little extra Os, little roxanol does wonders for the mind and respiratory status for any elderly COPDer. Get the bp down, get the heart rate down, it's fine.

Then C, one of the RTs comes into the room and says, "Guys...I just did a treatment a half hour ago and gave her some MedicationName then." Her gestures are clearly saying, chill, it's all good. She gently pushes a few people aside, and puts a simple mask on the patient. Because, hey, she's mouth-breathing so the nasal cannula is doing er, nothing for her. Good intervention.

J asks me what I heard. I shrug. "COPD lungs." I shrug again, and realize that I shouldn't take a shrugging-duh tone in a rapid response so I report what I heard. J nods. J also appears to be thinking shrug-and-duh of the situation. J asks somebody if they still need ICU, and when we get the go ahead, we go home.

And that was it.

Now, I know that is likely not a typical rapid response. Often times, we hear the chimes for rapid response and five minutes later we hear them again for a COR to the same room. And rapid response is a great system, and I'm sure it averts a lot of awful things. It's there for any nurse who needs extra help. And if I'd been nurse M, with L there, maybe I would want somebody different at my back. At least, a few months ago, I would have been alarmed at my guppy-breathing ninetysomething year old. I'd have at least wanted respiratory there. And C did show up, so it's a good system.

I can do this. This little bit. I would've had the sense to do the next step and put the cannula into the patient's mouth. I would have gotten a mask. Walked away from there feelin pretty okay. I was grateful to J, for putting me at the bedside. Was cool of her, and there's no rule that she has to be cool about anything.

The most fun thing? Coming back to my unit and people asking, "So...did you fix em?" Getting to nod and say: "We fixed em....Well, C fixed em. But yeah. Fixed."

That was cool.

And that's my story. I can handle a 1.5 alarm fire drill. Not too bad.

Code White

If you understand end-stage hepatic failure already, you don't need to look at the prelude post. You know how horrible it is. Otherwise, some of this might make more sense to peruse if you have the time/energy/interest/stomach for it.

A code white is a patient who is bleeding out in my hospital. Though nobody actually called a code white, this is what it was.

This is not the story of Sarah Johnson in room 42. 'Sarah Johnson' is not even close to the woman's real name, and we don't have a room 42. You don't know this patient and you never will. This is the story of what I learned about nursing, what I learned about how nurses learn, as I watched Sarah Johnson's body implode and I watched a team of people Sarah Johnson didn't know keep her alive.

I am bad at fiction, so what I'm telling you is true. Or at least, what I saw. These are the people I work with. It is my hope they don't hate my guts for writing about them. It is my hope, actually, that they never find out. But that's possibly not likely in the long run as I've showed a handful my desert pictures over on Betelgeuse. Dammit. So, in alphabetical order, I give you:

A, the monitor tech/unit secretary
D, travelling ICU RN
M, ICU RN, precepting P
P, ICU RN, orienting
R, SDU (stepdown) RN, who'd been my preceptor

and JustCallMeJo, yours truly, SDU RN

**************

Something big was happening in 42. It didn't take a genius or special spider-sense. I could see men in button down shirts with angry expressions on the phone at the other end of the nursing station. Doctors. Angry. Bad sign. I could see A, whose back was to me, typing furiously with a chart to his side, and the back of his head looked a warmer shade than normal. I could see P, hurrying in and out of 42, brow furrowed. I could hear the phone, and the phone, and the phone. M was calmer, but she was clearly busy...talking to A about paging this person, that person, clarifying with this MD this order, that order. I saw one of the docs I knew, one I'd seen intubate somebody before. She was wearing a scrub hat. Bad sign, meaning intubation was happening again. And I could see R, who was listening to D give him report, but whose eyes kept going up to 42. R is usually in the thick of things of a crisis, and was clearly keeping tabs on what was goin on.

I decided the best thing to do was my job. There was such a clusterfuck of people at 42 that what was needed was not me. Unless shouting and running happened, and then I would run, too. When bumping into P or M in the medroom, I told them, "If you need anything, let me know, my patients are fine and I can help." They said thank you, they're okay. M said this kindly, P said this with dubious belief. Or maybe that was just her stress level. Neither M or P knew me at all.

I noticed that R got his admit across the station from me, and B, the resource nurse was helping him and apparently nobody else. This is a bad sign because it meant that neither P, M, or D was available to lend a hand. Everybody is around to lend a hand when an admit comes. So I poked my head in, though by the time I got there, R had his patient settled.

I tried to stay out of the way of 42. Traffic slows because of rubberneckers. And I don't know enough to be useful. But as the evening progressed, one by one, MDs began to leave and the tension level decreased a little. I listened. I hovered, and I gathered that Johnson was bleeding, had been bleeding. P and M were back and forth, in and out of the room. P: "Where the hell are my platelets?!" M: "A, would you page respiratory for me please?"

(Rehab just called me. Can I come to work there tonight?...Er...sorry, been up all day. Besides, got a hot date with my best friend and her children today.)

D and R were doing their own thing. R busy, D mostly goofing off. I saw R hopping on the phone to page people for M and P. Getting stuff, helping. D hovered and told me that the patient was "bleeding so much that she had a yankauer up her ass". This is horrifying until you see how eminently practical and oddly humane it is. Would you rather have the patient bleeding out of her ass and lying in it because she's so heavy to move, have her family see her in that state...or would you rather find a way to keep her cleaner, even if it's a little, um, unorthodox? It sounds so horrible. It is horrible. So is the alternative.

P came out of the room at one point and I was the only one sitting there. Her expression said that I was clearly not her first choice. "JustCallMeJo, do you know where the blood bank is?" Yup, sure do. "Would you take these units down for me please because I'm only supposed to give them if her crit is x and we may not need them until midnight." Sure, I can do that. So I did, came back, loitered more. Maybe I could do something else. Learn something.

I caught little things. A needed to eat, and with his face that color, clearly needed to step away from the desk. There I was. "Will you watch monitor so I can get some food?" Sure. So I watch monitor, notice nothing more than occasional PVCs on two of R's patients, and take a huge number of calls for P/M. "M, Dr. Somebody is on the phone for you about Johnson." She nods, "Thanks. Johnson is P's patient, and I'll let her know." It was a gentle correction.

And I thought about that gentle correction. Here's a woman who can clearly handle this patient. She'd need help, of course, because no patient this complex gets better because of any one person, including and especially not because of any MD. Don't make me laugh. And what is this nurse doing? Holding up another nurse, supporting another nurse, one with less experience. And she did it....gracefully. I admire that. A good mentor is rare.

P needed more from the blood bank, and I was there again. "I need 2 units of FFP now, and see if they'll give you those two units." "Right. Two of FFP, two units if they'll give them." I returned with my hands full of stuff, which allowed me my first real look into the room.

love of god.

Bright lights, beeping, whirring. The patient was intubated. There was blood, yes, and oozing fluids. She was covered by a gown but she had what looked less like vaginal bleeding as what had been vaginal gushing. She was yellow. She was huge. She was massive, actually. X's marked the place on her feet where pulses would be if you could feel them. And there was a bank of IV pumps no less than five feet wide. Think about how wide five feet is. She had no less than seven lines infusing into her just from the IV pumps. And there were five lines hanging from the ceiling that were run-as-fast-as-you-cans, platelets mostly. Blood products and blood products. On the other side of the bed, there was a small fridge-sized portable dialysis running. (I didn't know this was a dialysis machine, I had to ask.) The patient had a tube down her throat, a ...let's see octo? lumen? subclavian in her right side...what do you call a subclavian with two or three "chicken feet", foley of course, the suction, and a vascath in her femoral, filtering blood, and oh, I think another miscellaneous IV bank in her left arm, too.

She was yellow and unconscious.

And seeping. Fluid seeping from her skin.

It appeared that either the bleeding was under control or the suction was taking it away and dumping it into tanks under the bed.

P and M were deep in conversation about some charting thing when I timidly walked in and handed them the blood stuff. "Thanks," they said, and then I kinda just didn't go away. I put my hands behind my back to not touch anything and I looked at the IV banks. Vasopressors, insulin, a few meds I didn't even know. "Is it, um, okay, if I look?" M nods, smiles. P shrugs, sure. P is focused on learning and stressed because well, this is her patient. She's digging this patient out of a deep fucking hole. I get that. I respect that.

So I try and stay out of the way, and listen. A GI doc is coming and gonna scope her and see if he can stop the bleed. I had to refresh my memory of hepatic failure later, but even as I heard that news, my eyes went huge because I was thinking: esophageal varices. I mean, the GI tract is really really fragile right now, right? This is risky, right? So my eyes popped and I shut up. Probably I just don't know what I'm talking about. I shut up, I listen. This is my job today.

P hung one of the platelet bags, and in a voice I hoped sounded unobtrusive, I asked, "So...P...you can just slam those in? You don't need to do a specific rate...?" She looks at me as if just noticing me for the first time. "Yeah, you can just run it with a bulb like this." "Because we at the opposite of caring about CHF type stuff, right?" "Yeah, her fluid volume is so low right now, it's hard to get a pressure."

And after that, P looked at me with less dubiousness. Maybe it occurred to her I wasn't a toad, nor was I a fluffy bimbo, and she had stuff she could teach me and I was more than willing to learn from her. At least, I hope that was it.

I tried to not get in the way, but I felt like I could watch. D hovered as the GI doc came in. D was having a ball. D was like this imp, buzzing in my ear. "I love this stuff....I love it when I'm so busy I can't even leave the room to take a piss....this is a great learning experience for P."

It wasn't just D that offered to teach me things, either. M said at one point, "You know, JustCallMeJo, she's got a really good example of scleral edema." P nodded, "Yeah, JustCallMeJo, come here and see this." I stood behind her, gloving up. P gently opened the patient's eyelid to show me, and then stepped back to allow me to do the same. My god. Her EYEBALL was swollen with pocketed fluid. There was something comforting to me about just gently touching this woman's forehead. I was careful. Her goddamn eyeball was swollen with fluid. I don't know what it is about things wrong with eyeballs that is just so fucking wrong.

But no time to think on this. We had things to do. Or rather, M and P had a lot to do, and I had getting out of the way to do. The GI doc arrived. Gowned up, machines brought in, things to move out of the way, more blood to get...

It was D who looked out for me. No special reason why that should be unusual, but R'd been my preceptor, and it seemed strange without him. Especially when What's Happening was in room 42, and in my limited time I've been on SDU...R thrives in a crisis. No time to think about it, though. D called me to come stand in a good spot and buzzed in my ear. When the doc would ask for something, D would hop up and get it. M and P were too busy. Handy, as I realized I still don't know my unit so well as to know where to find say, a tongue depressor. Who uses a fucking tongue depressor in ICU? Somebody who needs to open an unconscious patient's mouth, that's who. M and P were so slammed busy with the five foot wide banks of IVs and getting blood, slamming it in, trying to keep a blood pressure...I'm not sure that either of them got to actually see what was happening with the scope itself. P got to look up once. I'm not sure M saw it at all.

D was my running commentary. My eyes were riveted on the theatre happening in front of me, but I was listening. Once in a while, I'd fetch something. I would go eyeball my patients here and there, make sure they were breathing and doing fine. It helped a lot to know that A was at the tele desk. But I tried to be present as much as I could for the scope. (This scope = laproscopic exam from esophagus through duodenum) Some things D said I knew, some things I did not. "They're probably in the pyloric now...I've seen people come back with this and be completely fine after a transplant..." At one point, I think he was watching me and not the scope, and he said, "Welcome to ICU." I acknowledged I'd heard, but I was still looking.

Art school. You learn to look well. You learn to memorize gestures and colors.

I kept wondering to myself why R didn't hang and watch, too. Like I said, R's usually in the thick of things, and I was puzzled but I let it go. I tried to nudge him a little once or twice, but the effort fell flat. Possibly his new guy was a handful and he had a brief moment of respite, or there were already enough cooks in 42. After he'd lended a hand early on, he stayed out of the fray...fray-adjacent. I may be misreading, but there might have been brooding involved, brooding of unknown origin and no doubt not my business. I like R, he's a good guy and a good nurse, far better than me. He's certainly been patient with me. He belongs in ICU and due to life factors, he's not there at the moment. I let the invitation to come see the scope sit there, and then well...back into the fray.

The GI doc closed a bleed and he and his RN left. The scope showed a clot as huge as my hand in her stomach. It had been a helluva bleed. I'm not sure if he got IT, but he got one.

Cleanup time. This was something I felt like I could do, I know how to help, so I did. It took six of us to change the patient's linen, full of blood. And the second we got new sheets under her, the new ones began to darken with more blood. I could also take out the biohazard, I knew where that went. I can take out the trash, too, I know where that goes. More blood tubing? I can bring two types of blood tubing. So now I have learned which blood tubing is needed.

We were beginning to unwind. Sarah Johnson was gonna stop bleeding. Or at least slow the bleeding. This was what was unwinding. We saw the clamp. We got blood slammin in, and plates and expanders, and milk of amnesia so she never knows. Dialysis pumping it out and 14 or 15 lines pumping it in. Sarah Johnson is gonna make it through the night and today was definitely P's day.

Nobody knows that it's P's day but those of us who were there. She nailed it. She really did. I overheard her and M debriefing much later in the night, a really important thing to do after all that. "What would I have done if I had to do that by myself?" And you know what M said? "You would have had JustCallMeJo and R and D to back you up." She's right, and I think that's the best part of everything I learned that day. Had she been alone, I would have backed P up as best I could.

P was bulletproof at the bedside. Yeah, she was stressed, yeah she asked M stuff, her nerves were jangled, and M and D were rolling much better with the situation. But she got the job done, and that is *all* that matters to Sarah Johnson's family.

M was bulletproof because she didn't step in and do FOR P, she did better. She stepped aside and let the RN who will become another awesome person taking care of patients of this complexity do the job. This is not stuff you can learn from a textbook. This is stuff you can only learn by being there, and doing it. Somebody's very mortal coil is depending on you and the team of people you're with, and so this isn't something you can really practice. You do.

Think it's the doctors who "save lives"? Yeah whatever. They play their part, they go home.

Besides, I prefer the term "stopping someone from dying." Life saving is for pastoral types.

I fetched stuff. I took out the biohazard, I watched. I helped turn and asked questions. And what was cool is that D was there to buzz explanations to the least person in the whole group, i.e. me, the chick who took out the trash. And that chick was grateful to take out the trash, ...just to be there.

And A? A kept the chaos at bay. The static and noise of phone communication and flying orders and nonsense of delayed blood product and get me a respiratory therapist and no time to delay because this woman is bleeding to death. A rolled with that and also, by the way, watched the heart rhythms of 12 other patients.

R joined us as the cleanup happened. It's possible that he was having a completely different patient crisis, of which I wasn't even aware.

Sarah Johnson's alive (or was when we left), survived the night and neither she nor her family will know what was involved to make that so.

You have no idea how proud I am to be the person who fetched the extra blood tubing.

During cleanup, D went back to his goofing-off self, munching out of a bag of popcorn. ("I'm really hungry. Is that weird to be hungry after I just watched a GI scope?" "I think it's healthy.") He asked me, "So is this better than rehab?" Rather than answer, I grinned back. A grin that wasn't just 'yes' it was 'hell fucking yes'. It was a dirty grin, an evil grin and I didn't actually intend to flash it at him. So I turned back to fiddle with the biohazard bag, but not before the point was made.

And I didn't sleep. I was awake 23h. And this post is a poor reflection of what happened. I don't think I really caught it all. It's an echo of an echo two days later.

I don't know if Sarah Johnson is alive today. When I told Katie the cliffnotes version of this story, she said, "Well, you can't....maintain that kind of thing, can you...? Putting all that blood in nonstop? I mean, what's gonna happen?"

I don't know. I really don't know.

I know it'll happen again sometime. Liver failure does. And I'll know which blood tubing is the right one, and where to find sharps containers.

That's worth something to somebody, isn't it?

Liver failure: prelude to 'Code White'

You need to read this post to understand the one I'll be writing down next. Because, now that I'm pulling my thoughts together, there are two big things I learned about as a nurse this week. One is a few things about clinical pathophys and presentation of liver failure. The other is a few things about how nurses treat and respond to the crisis of liver failure, and in this case fulminant liver failure.

Liver failure is a bad way to go. Most nurses can tell you there are better ways to go than others, and liver failure is not a good one. If you're considering alcoholism as a life choice, please reconsider. Massive MI is a better way to go, but the problem with that one is that in lathering up those arteries, you might just end up with the long suffering of CHF instead. Also, do NOT overdose on tylenol, as this leads to liver failure as well. Use condoms, as you do not want Hep B or Hep C. Wash your hands, as you do not want Hep A. If you use IV street drugs, (not a big recommendation for a host of other reasons), for god's sake, autoclave.

Kim from Emergiblog is an ED RN, and she rocks, as does her blog. Months ago, she did a gutwrenching post, and it's beautiful and has stuck with me since. Here it is.

Some patients seem to hit you on an emotional level, as Kim's did. Some patients interest you clinically, as this one did. Nurses do not tend to be the people in your health care world who forget ever that you're a person. I touched this woman's forehead to see her eyes, and I did so gently because this woman happened to be somebody's Mom, somebody's wife. But as a clinician, I was interested in the machine of human beings working their asses off to save her life. I was interested in what was going on with her body. I was interested in who did what, what roles functioned to do this thing to keep her alive.

This is why this is the first post I'm gonna label "learning ICU." Not because I haven't been for the past 6 weeks, but this is the first time I might have learned some vocabulary words to tell you about critical care nursing.

For non-clinical people:
You know that alcohol abuse and viral hepatitus can crash your liver. You might not know what your liver actually does for you. I mean to say that you know these things are bad, but you don't have a specific picture of why, exactly. Something to do with being yellow, probably.

* Your liver filters broken blood cells, bacteria and nitrogen out of your blood. Let us consider the example of "laughing gas", which is nitrous oxide. What happens when there's too much nitrogen (which is actually in the form of ammonia) in your blood? In small doses, you may feel silly. In toxic amounts, you're beyond crazy and you're in a coma.

* Your liver gets rid of this gunk called bilirubin out of your body. Bilirubin is what makes the skin yellow in people with hepatitis and newborn babies, whose livers learn after they're born to break down the bilirubin. Most babies are born a little jaundiced and it clears in a matter of 2 days. I had hepatitis in 1990, because the mono...a virus called Epstein-Barr, overloaded my liver. I was yellow and felt like hell for 6 months.

* Your liver metabolizes drugs, vitamins and hormones...meaning it breaks them into substances your body can use. Without that ability, your cells aren't getting fed nutrition, and drugs that your nurse gives you to do important things like regulate your blood pressure or heart rate or whatever, are not as effective.

* Your liver helps regulate blood glucose via glycogen stores...glucose = "cell food". It also metabolizes fats. A double-whammy of nutritional deficiency.

* Your liver makes certain proteins, one of which is called albumin, others relate to blood clotting called fibrinogen and prothrombin. Let's start with clotting factors...that's easy. If your plasma, the goo your red blood cells float in, does not have clotting factors, you don't clot. Ergo, you bleed. The less factor and fibrinogen in the blood, the more bleeding. You can see where this is going.

* Albumin is a happy little molecule that transports hormones around your body. It's bigger function, however, comes from the fact that it's big. I want you to go for a moment back to high school biology and chemistry and we're gonna talk about osmosis. Big molecules act like sponges and draw water to them. Wikipedia has a wonderfully egghead explanation. But what I need you to know is that big molecules suck water closer until there's stability between say, what's inside your veins and what's across the membrane of the vessel wall.

Again, with the what does this mean thing? If you don't have albumin, you leak. You leak abundantly. Your blood vessels shrivel up from losing blood volume and you lose blood pressure itself and your body swells up with fluid because all the water IN your body isn't usable to you. You swell with so many pounds of useless fluid that I can make a thumbprint an inch fucking deep into your foot. Your skin leaks clearish-yellowy fluid from any cracks of incisions made, such as IV sites, or anywhere your skin may have been broken.

You are a giGANTic sack of fluid-filled skin oozing your yellow self everywhere, beyond cognizance because of the nitrogen or ability to breathe on your own because of the metabolic acidosis. Your kidneys are dead because your kidneys require blood pressure. Then there's that other small detail of not having any blood pressure, so your heart is gasping for something to do in the time it has before your blood pH and the lack of usable potassium stops it dead. You're probably getting IV lactulose, which is a medication designed to give you constant bowel movements because that gets rid of some of the nitrogen. Oh, and there's the bleeding in addition to the oozing and the shitting. And the most likely place you'lll bleed? Your GI tract. What blood you have, since it can't go through the liver anymore, rerouts often through the veins in the bottom part of your esophagus. These are called esophageal varices. Your GI tract? Big long tube from your mouth to your ass and so you're shitting copiously, and now you're bleeding copiously out of your ass, too.

Fortunately, at this point, you are probably beyond awareness of any of this.

The unfortunate part is that your family members who love you might be watching.

love
of
god

This is a PERSON I'm talking about.

This is a PERSON.

christ.

geezusfuckingchrist

I know you're not wondering now why I had to write this to get it out.

I'm so glad I lost the belief that god/dess/GiantTurtle is responsible for anything that happens anymore. Because I'd be mad if I did.

Instead, I am staring at a gaping hole of entropic causality. I don't feel better about it than you do, probably, but I am not angry. I believe 'existential horror' covers it. There can only be two outcomes of existential horror. Sartre found it in a bullet. I think the only way out is compassion. I'm certainly not the first to draw that conclusion. Taking that complete rainbow in the mist and giving it away as fast and fully and completely as you are humanly able. And that's why there's a part two to this story.

Something I want you to know, too. Lest you are one of those assholes who think that alcoholics deserve this fate, I will tell you that this patient was not in hepatic failure because of alcohol. Nor was it viral. There was not a single lifestyle predisposing factor that caused her liver to die.

Nobody deserves what that woman got.